HomeMy WebLinkAbout026-1048-30-200
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER a yVp Y- c *
ADDRESS , )e "i a~/nati ~ 'w'--
SUBDIVISION / CSM# LOT
SECTION N-R_~W, Town
of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
/6B 0 s c~f. c-
a6
I
3
J
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
• /l
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: hi;~u,~s7`rs~,~ Liquid Capacity: /
Setback from: WellZ&"40ouse .2,j' Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length ~ 7 Number of trenches 2
Distance & Direction to nearest prop. line: /mod'
Setback from: well: A ousel Other
ELEVATIONS
Building Sewer ST Inlet. ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: PLUMBER ON JOB:
LICENSE NUMBER: y-
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
r
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Permit is TODD ❑ City F] Village a Town of: State PI
x
CST BM Elev.: Insp. BM Elev.: BM D script on: Parcel Tax No.:
-
TANK INFORMATION ELEVATION DATA / QV.
TYPE MANUFACTURER CAPACITY STATION BS HI FS Septic Benchmark 3, fj Dosing
ration Bldg. Sewer
Ae
Holding St/Inlet
TANK SETBACK INFORMATION St 140 Outlet
Vent
TANK TO P/ L WELL BLDG. Airito ntake ROAD Dt Inlet
Ar
Septic lw r NA Dt Bottom
Dosin NA Header 5 7977'
Aeration N Dist. Pipe Y91 C 7
S r
Holdi Bot. System 7Y
PUMP/ SIPHON INFORMATION Final Grade
Manufac Demand S -77.
Model Number GLea~ 2 D~,
TDH L' Friction System Ft
Forcemain Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Tr nches PIT No. Of Pits Inside Dia. Depth
DIMENSION S ,
S I DIME I N
SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEAC Manufacturer:
SETBACK
INFORMATION Type O rl-C~x~ r a r ' BER Mode Number:-
System: -6r"'C10.5 OR UNIT
DISTRIBUTION SYSTEM
Header A%ftnTi4"eI- Distribution Pipe(s x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Richmond.1 .30.18W, SW, SW, Lot 4, county Road G
D
Plan revision required? ❑ Yes [_lo
Use other side for additional information. /d2 ~Q S--(JAI
SBD-6710 (R 05/91) Date Inspector's Signat re Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building water systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less county Madison
than 8 112 x 11 inches in size. i
• See reverse side for instructions for completing this application State Sanita~~rmitN2
The information you provide may be used by other government agency programs ❑ Check it revision to previous application
[Privacy Law, s. 15-04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
id & 1/4-4) 1/4, S T 3D , N, R (or
Property Owner's Mailing Address Lot Number Block Number
d'
City, State Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE F BUILDING: (check one) ❑ State Owned City Nearest Roa
❑ Vilage
Public Eg-1 or 2 Family Dwelling - No. of bedrooms Town OF r f► 6 G~
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 E] Apartment/ Condo Q a2 l J0 T G
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1- gNew, 2- ❑ Replacement 3- ❑ Replacement of 4- ❑ Reconnection of 5- Repair of an
System SystemTank OnlyExisting System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 .Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2- Absorp. Area 3. Absorp- Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft-) Proposed (sq. ft.) (Gals/day/sq. ft-) (Min./inch) Elevation
Feet G~ Feet
Capacity
VII. TANK in gallonTotal # of Prefab. Site Fiber- Exper.
INFORMATION. Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank ad 1!w4 GJeSy.e f~ ,L~J.. ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature*( Stamps) P PRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
0
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate slue Issuing Agent Signature (No St imps)
Surcharge fee)
(Approved ❑ Owner Given Initial (P r
/ Adverse Determination l ~J
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBO-6398 (R. 05194) DISTRIBUTION: Original to County, One copy To: Safety & Ruildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
1 All revisions to this permit must be approved by the permit issuing authority-
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The se,otic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7-
VII. Tank information. Fill in the capacity of every new/or exis:ing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
G lc~ av GL
t
~J ~ - .SX S? Tre~cG~eS
®~s C
eon
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page _ of
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
r
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARC y
1
dimensioned, north arrow, and location and distance to nearest road. Nor .10%
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION Y! DBIr" 5
PROPERTY OWNER: PROPERTY LOCATION
ev7 QL$ e/ GOVT. LOT :5 1/4~ TYC N,~ y.
PROPERTY OWNERMAILING ADDRE~Sg LOT # BLOCK # SUBD. TRR CSM It.;
CITY TATE~ / ZIP CODE PHONE NUMBER ❑CI ❑VI LAGE jg O ~Nl A R
N-1 Oc t c~l/!?c
New Construction Use Residential / Number of bedrooms [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 1 gpd Recommended design loading rate _bed, gpd/ft2-trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate ;~r bed, gpd/ft2~trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations 1$r_.
Parent material Flood plain elevation, if applicable ft
S = Suitable for system CO VENTIONAL MOUND 77Z7UND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem S❑ S❑ U ❑ U KS El U ❑ S U ❑ S -E"
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed TwIch
r
Ground D
elev.
~~ft.
Depth to
limiting
fact
Remarks:
Boring #
44'tt.}f~v'•hvvv~"•• / V C ✓ ~~I / 4_r
C
Ground
elev.
Depth to
limiting
factor
Remarks:
CST Name:-Please Print Phone:
Address: a, m rI2-~
Signature: Date: CST Number:
7- 7
PROPERTYOWNER4~z~ ~SOIL DESCRIPTION REPORT Page _of~
r.
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Ground 00,
elev~oe
/4v-9-7- ft.
Depth to
limiting
factor
Remarks:
Boring #
0 2 7-
Ground
elev.
ft.
Depth to
limiting
factor
J1~
Remarks:
Boring #
' O ~ ~ es~-.ter ~ ~ l/ ~
Ground
elev.
ft.
Depth to
limiting
factor
~Aw"L
r- ,7 Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
Soil Test Plot Plan
Project Name Geln Basel Byro Bird Jr.
Address 1462 95th St.
New Richmond Wi 54017 M #3479
Lot Subdivision Date 11/17/95
SW 1/4 SW 1 /4516 T 30 N/1318 W Township Richmond
❑ Boring O Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft.Base of White Stake Red Ribbon
System Elevation 96.8 * H R P Same as Benchmark
221' Property Line M
120'
n
0
7d
25' B-115' 15' B-4
a.
Pro 3
Bedroom 35'
House
&-3
Pri A Rep A
75'
0% Slope
t.4_ 30'
B-2 B-5
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St(. Croix County
OWNER/BUYER M^ LC 0
MAILING ADDRESS . C , 1g c N t t : vY10 to J L10 /
PROPERTY ADDRESS C r) 41?Z ,;Ll
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE ( L J-
PROPERTY LOCATION 1/4, < v~ 1/4, Section T_a_O_N-R_[y _W
TOWN OF C ~ hN 0 \AA ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIEDSURVEY MAP , VOLUME C PAGE LOT NUMBER
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed
by licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED:
DATE: Z' 7 -
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - 100
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
owner of property p f f/1
Location of property-5 ti~ 1/4 S V 1/4, Sectio T-a-o"-L W
Township t.Mailingaddress .Q,C), 601< 5g
~ LJ 41c t 7
Address of site ea
Subdivision name es gyn.. 1-3 3 Lot no.
Other homes on property? Yes No
Previous owner of property 4
Total size of property - F
Total size of parcels 2 d
Date parcel was created ~t-G-
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes _X,_No
Volume to and Page Number 171-1--. as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds.as Document No. 6'.3 79,Qd , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
Signature of Applicant Co-Applicant
12-
7-Date of Signature Date of Signature
FILED
l l DEC 5 1995 .00
5
KATHLEEN H. WALSH
Register of Deeds
SL Croix Co., WI tS
5371.30
CERTIFIED SURVEY MAP
,Located in part of the SWJ of :the.SWi.of-Section..16,.T30N,"Rl8W, Town of
Richmond, St. Croix County, Wisconsin, being lot 2 of certified survey
map Volume "10" Page 2784.
L_E_G_E_N_D_
Aluminum County Section / North line of the SWk, of the SW%
Monument Found S89°59'00"W
• 1" x 24" Iron Pipe Set, Weighing 1.68 lbs / 122.95'
Per linear foot
0 1" x 24" Iron Pipe Found, Weighing 1.68 p
i lbs Per linear foot h;` ;ws:
. 100' Roadway Setback Line ~dC,' ;
X Sk Corner position established from
ties, see County Surveyor for ties. / ~~~p• ALL
Z( + 'sue. .
.07
LOT 3 ~N~
o v> ~c i 5.47 Acres
-P Ln M
0 o°°mp / h~~• 238,281 SQ.FT.
2C
N
L
L
0 4-)
~O
o ~ I CoI
~;C e / S89°33'22"W 541.06' _ z
M- N 270.53' 270.53' n QI
N _ll
M7 ° LOT 4 LOT 5 M 3
m
m v>
a~
0 QI
o WI
00
4.20 Acres 4.22 Acres 3 F-I
N Inc. R/W `o Inc. R/W - `n ¢I
LLOT ( N c w 183,106 SQ.FT. 183,749 SQ.FTm °o -45
CD 0
L n u) to 0 I
'-1. 10 `0 4.04 Acres o 4.04 Acres e,
V(:)' Exc. R/W 3 Exc. R/W
~0 vJ 1~r J• 175,820 SQ.FT. m 1757820 SQ.FT.
174 - zED
O N l ~I O
N 0........................... M.... Z '951
SW Corner co Sk Corner
Section 16 N89°33'22"E 541.06' Section 16
270.53' J 270.53' _
-97Q :T4 2-70-551
'89°56'40"E 541.09' M 4 atu,ir
South line of the SWk C. T. H. G 05614011E
S89°56'40"E 1309.56'
768.47' ~ . r _ W
o rded
UiJPLA EL~ LANDS idaysof
:a+r•,+rd state
that., t►e
OWNER °,g ; •.r ~yi7i
Glenn A. & Karen M. Basel
1462 95th Avenue
New Richmond, WI 54017
SCALE IN FEET 111=200'
job No. 95-101
This instrument drafted by Randy Nyhagen 100 50 0 200 400
VOL. 11 PAGE 3023
%
I,
u ~
5~ 7320 State Bar of Wisconsin Form 2 - 19V_
ii WARRANTY DEED ~ l
DOCUMENT NO. VOL115vPAGE 29
II
ST. Cn !X C0., INI
R...'d %;r Rocord it
Glenn A. Basel and Karen M. Basel, DEC 8 1995
-_luS n an wi e, -
conveys and warrants to Todd R. Marek and Kelly Moenirn2_ o~ t.~rpfp3yg <
I both sin 1>; perms as joint tenants,-
00
I+ /0
i
THIS SPACE RESERVED FOR RECORDING DATA
NAME AND RETURN ADDRESS
~ I r, • X816 tt//
the following described real estate in St" Croix 9 (r/~ S7V/-/
County, State of Wisconsin:
ii
I
(Parcel Identification Number)
i II 4y
I
! Part of 571/4 of SW1/4 of Section 16-30-18 described as follows: Lot 4 of
I~ Certified Survey Map filed December 5, 1995, in Vol. [`111', Page 3023. ~j
l ~
II ~
~j
This property has restrictive covenants, recorded with St. Croix County
Register of deeds, recorded on July 22, 1994, Vol. 1088 Page 104.
S ~D
i
Thig is not homestead property. It hr
(is not)
Exception to warranties: Easements, restrictions and rights-of-way of record, if any.
it
Dec. r 95
Dated this day of '19
!
I~
(SEAL) (SEAL)
Glenn A. Basel Kiaren M. Basel
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT 'f
I~ STATEOF WISCONSIN
Signature(s) y
ss.
St_ Croix
l~ County. ,
authenticated this day of , 19 P%=son ly came before me this 7th day of
Decetaer 1995_ the above named
Glom A. Basel and Karen M. Basel
'band and wife,
TITLE: MEMBER STATE BAR OF WISCONSIN -
(If not, -
authorized by §706.06, Wis. Slats.) to tlOe amom-la to be the person S--_ - who executed the
it
Connie M. Gullixson f r rument and acknowledge C.
II THIS INSTRUMENT WAS DRAFTED BY Notary Public
I~ Kristin 0gland State of Wisconsin
Caxtnie M. Gullixson
Attorney at Law _ Newf. Public St. Croix County, Wis.
! (Signatures may be authenticated or acknowledged. Both are not Nv ommmission is permanent. (If not, state expiration date:
l necessary.) L~-14 1997
"Names or persons signing in any capacity should be typed or printed below their signatures-
WARRANTY DEED STATE BAR OF %%tSC0N_1Z% Wisconsin Legal Blank Co.. Inc.
FORM No. - NNC Milwaukee. Wis. !i
sea.,